Diabetes is treatable, but people with diabetes have a greater risk of developing cardiovascular disease (CVD) than people who do not have diabetes. Indeed, adults with diabetes are two to four times more likely to develop heart disease or a stroke than adults without diabetes. The reason for this is because people with diabetes, particularly type-2 diabetes (T2DM), may have specific conditions that contribute to their risk of developing CVD. These include high blood pressure, abnormal cholesterol and high triglycerides, obesity, physical inactivity, high and poorly controlled blood sugars, and smoking.

Keeping your diabetes under control by managing the risk factors will help protect your heart health. Most people with T2DM are prone to accelerated atherosclerosis, and could ultimately die of cardiovascular disease (CVD). Many will die prematurely. Overall, the incidence of CVD is declining, but for people with diabetes it is increasing.

Much of diabetes care is the prevention of CVD by modifying blood pressure, blood glucose, and lipids, and this involves both medical therapies, and lifestyle changes, as Dr Roni Sharvanu Saha, Consultant in Acute Medicine, Diabetes and Endocrinology at St George's Hospital, London, explains:

Blood pressure and glycaemic control

Blood pressure and glycaemic control often require multiple drug therapies, which are less likely to produce side effects than a signal agent. Glycaemic control is important for controlling both macro and micro vascular disease. The former includes myocardial infarction and stroke; the prime causes of excess mortality in diabetes. Preventing microvascular complications is important to reduce the risk of retinopathy, and nephropathy.

Insulin therapy

Increasing numbers of people with T2DM are using insulin therapy to achieve tight glycaemic control. The challenge is to reconcile reduced HbA1c with the risk of hypoglycaemia. There is an important debate between tight and adequate glycaemic control. A 2014 Australian study reported in the New England Journal of Medicine suggests that there is no evidence that tight glucose control leads to long-term benefits with respect to mortality or macrovascular events.

Antihypertensive medication

The majority of people with T2DM whose blood pressure is not within the 140/80-range will require antihypertensive medication, which is usually an angiotensin converting enzyme (ACE) inhibitor. If the target blood pressure is not achieved, a calcium channel blocker or diuretic can be taken in combination. ACE inhibitors are inappropriate for pregnant women, and may be a less effective alternative for those of Afro Caribbean descent where a calcium channel blocker may be more effective.

Lipid lowering

Lipids are fat-like substances in the blood, and cholesterol is one type of lipid. In order for lipids to travel in the blood they must be coated with protein: lipoprotein. Excess cholesterol is detected by measuring lipoprotein. High cholesterol is a major controllable risk factor for CVD. As blood cholesterol rises, so does the risk of CVD. Recommended targets for cholesterol lowering in diabetes are total cholesterol bad cholesterol,

People with high cholesterol may be prescribed a statin, which is a group of medications that can lower bad cholesterol, and thereby reduce the risk of CVD, as Professor Olaf Wendler,Consultant Cardiothoracic Surgeon at King’s College Hospital and Professor of Cardiac Surgery at King’s College London explains :

However, high cholesterol is just one risk, and statins are usually offered to people who have been diagnosed with a form of CVD, or whose personal and family medical histories suggest they are likely to develop CVD at some point over the next 10 years.

Side effects

Statins are tablets to be taken at the same time once a day, and in most cases, will need to continue for life, as stopping the medication will cause high cholesterol levels to return within a few weeks.

There are significant risks associated with mixing statins and grapefruit, which include muscle breakdown, liver damage and kidney failure. Statins also carry other risks, such as digestive problems, increased blood sugar and neurological side effects, including confusion and memory loss.

Lifestyle

In addition to drugs, people with T2DM experiencing hypertension, and high cholesterol are encouraged to eat a healthy diet low in saturated fats, exercise regularly, stop smoking, and reduce salt and alcohol. Smoking is particularly harmful for people with diabetes since it increases the risk of macrovascular disease and microvascular complications.

Takeaways

Diabetes is closely associated with CVD. Heart attack and stroke are the major causes of premature death in people with diabetes. With the rising prevalence of diabetes, especially in developed countries, the double jeopardy of diabetes and CVD is set to result in an explosion unless preventive action is taken.

Managing T2DM involves a combination of drugs and lifestyle. Self-management is enhanced by increased knowledge of the condition. People living with T2DM can either prevent or slow the onset of CVD by increasing their physical exercise, eating a healthy balanced diet, controlling their weight, and giving up smoking.

Management of CKD includes glycaemic control, blood pressure control and smoking cessation

Diabetes and kidney disease

Diabetic kidney disease has become an epidemic; people living with diabetes need to become more active in its management in order to either slow the onset of kidney disease or to stabilize it.

It is not easy.

People with severe kidney disease often do not realize it. Primary care doctors often do not recognise it, and fail to refer patients to specialists. According to the US Renal Data System, 42% of patients with end-stage renal disease (ESRD) had not seen a kidney specialist or nephrologist prior to beginning therapy.

Kidney failure is one of the most severe and life-threatening complications of diabetes. About 30% of people with type-1 diabetes, and between 10% and 40% of those with type-2 diabetes eventually will suffer from kidney failure. Over the next decade, it is projected that twice as many people will suffer from diabetes related kidney failure.

Silent killer

"There is an explosion of kidney disease, but a lot of doctors are not aware of the strong association with diabetes, cardiovascular disease and hypertension," says Dr Robert Stanton, chief of the kidney and hypertension section at Harvard’sJoslin Diabetes Center. "You can slow down kidney disease, and maybe stabilize it. But if you wait too long, very little can be done," says Stanton.

Kidney damage from diabetes (diabetic nephropathy) accounts for 35% of people with ESRD. In 2015 some 35,000 people in the UK required kidney dialysis. In the US, more than 100,000 people are diagnosed with kidney failure each year, and an estimated 31 million people have chronic kidney disease (CKD). In India there are some eight million people suffering from chronic kidney failure. Lloyd Vincent, Senior Consultant Nephrologist at Narayana Hrudayalaya, Bangalore, India, here explains how diabetes control is related to kidney function:

The only way to find out for sure whether you have CKD is through specific blood and urine tests. Once detected, CKD can be treated with medicines and lifestyle changes. These treatments usually decrease the rate at which CKD worsens, and can prevent additional health problems.

Your kidneys and diabetes

Your kidneys perform vital functions such as filtering your blood and stimulating your red blood cell production. Diabetes damages small blood vessels in your body, including those in your kidneys. This means your kidneys cannot clean your blood properly, and wastes cannot be removed from your blood, which means kidney failure. Diabetes may also result in nerve damage, which can cause difficulty in emptying your bladder. The pressure resulting from a full bladder can back-up and injure your kidneys. Also, if urine remains in your bladder for a long time, you can develop an infection from the rapid growth of bacteria in urine, and this can affect your kidneys.

Early signs

An early sign of diabetic kidney disease (DKD) is an increased excretion of albumin in the urine. Albumin is present long before usual tests show evidence of kidney disease. Weight gain, high blood pressure, ankle swelling, and the need to use the bathroom more at night are also signs. A person with diabetes should have their blood, urine and blood pressure checked at least once a year. Maintaining control of diabetes can lower the risk of developing severe kidney disease.

Late signs

As kidneys fail, blood urea nitrogen (BUN) levels rise, as do levels of creatinine in your blood. Signs of late stage kidney disease include nausea, vomiting, appetite loss, weakness, fatigue, itching, muscle cramps (especially in the legs), and anaemia. Also, a person with diabetes might find they need less insulin, which is because diseased kidneys cause less breakdown of insulin.

Takeaways

Diabetic kidney disease is essentially a microvascular complication, which triggers a vicious circle by promoting macrovascular processes as well. Early intervention is crucial and prevention encouraged. The most effective strategies include: glycaemic control, blood pressure control, and smoking cessation.